Home Sleep Test - Clinic Order Form
Thank you for choosing Belun Ring home sleep test.  
Please fill in this order form.  
We will send you the device within 3 working days.
Report will be available within 3 working days from return of device.
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Patient Information
This information will be shown in the test report.
Patient name *
Patient number
As an unique identifier of the patient. Up to 12 letters or numbers.  
Age *
Gender *
Height *
cm
Weight *
kg
Test Start Date *
The device will be sent to your clinic before this date.
MM
/
DD
/
YYYY
Test End Date
The device will be sent back to Belun on this date.
MM
/
DD
/
YYYY
If the device will be delivered to the patient, please provide his/her contact information. 
Patient address
Patient phone number
Clinic Information
Where we will send the device, report and invoice to.
Doctor's Name *
Company Name *
For billing
Contact Person *
Who is handling this test order
Phone Number *
We will contact you by call and WhatsApp
Address
Address of the clinic if you want the device to be delivered there. 
Email *
We will send report and invoice by email.
Please read our privacy policy at https://shop.beluntech.com/policies/privacy-policy. I consent to provide the personal data for the purpose of carrying out the home sleep test. *
For any questions, please contact us at
Email: cs@beluntech.com
Phone: +852-3706-5640
WhatsApp: https://wa.me/85237065640
©2020-2021, Belun Technology Company Limited. All rights reserved.
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